The State of Telehealth Reimbursement
Telehealth is a fast growing industry, expected to be over $34 billion world-wide by 2020. Research shows that consumers have a strong desire to adopt telemedicine. In a national study of over 2,000 consumers, 64% said they would be willing to have a telehealth visit with their doctor via video. In another study by the Society of Participatory Medicine, a staggering 84% believe self-tracking with devices and apps, and sharing it with their health team, would help manage their health.
While the market seems to be moving towards telehealth, state laws and reimbursement are lagging behind. One of the key obstacles has been that telehealth tools have not provided a way for consumers to conduct an exam from home beyond using audio and video capabilities. TytoCare provides this “missing link” by enabling a comprehensive medical examination of the patient at home that can be conducted in real time with a physician for an immediate diagnosis, or as “exam and forward” for a later consult. Having medical exam data will help optimize reimbursement potential.
- Telehealth resource centers http://www.telehealthresourcecenter.org/
- American Telemedicine Association (ATA) http://www.americantelemed.org/
- CCHP state parity laws http://www.cchpca.org/sites/default/files/resources/50%20STATE%20COMPLETE%20REPORT%20PASSWORD%20AUG%202016_1.pdf
- ATA State Coverage Gap Analysis https://www.americantelemed.org/policy-page/state-telemedicine-gaps-reports
- CCHP Summary of 2018 Medicare Fee Schedule https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
- National Telehealth Policy Resource Center http://cchpca.org/state-laws-and-reimbursement-policies provides an interactive map for telehealth state laws and reimbursement policies, including Medicaid
- Medicaid’s website provides an overview of telehealth policies https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/telemedicine.html
There are several modifiers that can be used, depending payer guidelines so it is best to contact specific payers directly to understand their requirements. Until this year, the standard telemedicine modifier was GT, so for example, a new patient consultation that is “via interactive audio and video telecommunications systems” would have been be submitted as 99201 GT.
Starting in 2018, CMS has indicated their preference in eliminating the GT modifier in most cases and using the POS code 02 in its place. Separately, the AMA has been promoting the 95 modifier in certain encounters.
1) Commercial Payers
32 states and the District of Columbia have parity laws that mandate commercial payers provide coverage and reimbursement for telemedicine services as in-person services. Many other insurers cover at least some telehealth service. Insurers are starting to recognize the benefits of reimbursement for telehealth, in some cases going beyond the parity law in their state. For example, IBC recently announced it would allow for telehealth visits in Pennsylvania, a state where no parity law exists. Some parity legislation recognizes the importance of exam tools that can replicate in person visits, such as Virginia, which mandates exam replication in order to prescribe remotely.
Solutions like TytoCare that enable a comprehensive home examination show promise for obtaining reimbursement for healthcare visits in the future.
Approximately 49 million Americans are enrolled in Medicare. Many telehealth services such as remote radiology, pathology and some cardiology are covered simply as physician services. For traditional fee-for-service benefits are based on “originating site” restrictions and apply only to those living in rural areas. In these cases, Medicare covers physician services as long as they use videoconferencing. To check eligibility based on location visit http://datawarehouse.hrsa.gov/telehealthadvisor/telehealtheligibility.aspx. Distant Site Practitioners may also receive payment for covered telehealth services (subject to state law) if they are physicians, nurses, PAs, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, dietitians or nutrition professionals, and clinical psychologists and social workers (with some restrictions).
Although Medicare fee-for-service beneficiaries is limited primarily due to originating site restrictions, there are approximately 14 million Medicare Advantage (managed care) enrollees who have complete flexibility in using telehealth as long as their provider offers the service. Many commercial plans have added telemedicine as a supplemental benefit, realizing the clear value and benefit that exist for the Medicare population, showing a trend in the right direction for the telehealth market.
In a very exciting and important development, starting in 2018 CMS/Medicare has indicated it plans to start covering additional telehealth use-cases. In addition to expanding a few categories of telehealth, CMS increased coverage of remote patient monitoring (RPM) services that currently utilize CPT 99091. This exapnded coverage is noted by CMS as an interim step until 2019 when they will consider adding more specific codes in place of the broad and non-specific 99091. Of particular interest for prescribers looking to implement telehealth in the home, the new RPM coverage is not subject to the traditional Medicare telehealth geographic and originating site restrictions. In particular, RPM services can be provided in the home, and in both rural and urban areas.
Medicaid is America’s largest medical and health-related funding source for the poor. Though the program is jointly funded by federal and state governments, the federal government allows each state to set many features for their programs. States may reimburse for telehealth under Medicaid so long as the service satisfies federal requirements of efficiency, economy and quality of care. Extensive control is given to states to decide how to structure and administer their Medicaid telehealth policy. Unfortunately, no two states are alike in how telehealth is actually defined and regulated. These differences create a confusing environment for those using telehealth, particularly health care systems that provide care in multiple states.
To learn more about Medicaid’s telemedicine policies, visit https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/telemedicine.html. You can also visit the National Telehealth Policy Resource Center http://cchpca.org/state-laws-and-reimbursement-policies to search for Medicaid coverage in your state.